title: Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein.
abstract: OBJECTIVE
  The true rate of intraoperative cerebrospinal fluid (iCSF) leak during pituitary surgery is not well known because small iCSF leaks are easily missed. Our objective is to determine the rate and significance of iCSF leak in endoscopic pituitary surgery with intrathecal (IT) fluorescein administration and determine factors predictive of iCSF leak.
  
  
  METHODS
  IT fluorescein was administered in 203 consecutive endoscopic, endonasal pituitary surgeries. The rate of iCSF leak was noted prospectively and correlated with tumor diameter and volume, gross total resection, and the learning curve. Postoperative CSF leak rate, complications, and nasoseptal flap utility were also investigated.
  
  
  RESULTS
  The rate of iCSF leak was 61% overall, 44% for tumors<2 cm compared to 72% for tumors≥2 cm and 35% for tumors<1.5 cm3 compared to 68% for those≥1.5 cm3 (P<0.001). Postoperative CSF leak was significantly lower after the first 50 cases (0.7% vs. 10%; P<0.005) with overall leak of 3%. For tumors>2 cm, the introduction of nasoseptal flap reduced the rate of postoperative CSF leak from 5.6% to 1.4%. We did not find any complications clearly related with the use of IT fluorescein.
  
  
  CONCLUSIONS
  The rate of iCSF leak during endoscopic pituitary surgery using IT fluorescein is higher than previously reported. Tumor diameter and volume are best predictors of the risk of iCSF leak. Based on this knowledge and a closure algorithm that includes a lumbar drain and nasoseptal flap for larger tumors (>2.5 cm), we can conclude that the postoperative CSF leak rate remains exceptionally low, particularly once the learning curve is overcome.
authors.affiliation: Department of Neurosurgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Department of Neurosurgery, RWTH, Aachen, Germany.
authors.forename: Dejan
authors.initials: D
authors.lastname: Jakimovski
authors.affiliation: Department of Neuroradiology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.
authors.forename: Gregory
authors.initials: G
authors.lastname: Bonci
authors.affiliation: Department of Neurosurgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.
authors.forename: Moshe
authors.initials: M
authors.lastname: Attia
authors.affiliation: Department of Public Health, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.
authors.forename: Huibo
authors.initials: H
authors.lastname: Shao
authors.affiliation: Department of Neurosurgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.
authors.forename: Christoph
authors.initials: C
authors.lastname: Hofstetter
authors.affiliation: Department of Neuroradiology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.
authors.forename: Apostolos J
authors.initials: AJ
authors.lastname: Tsiouris
authors.affiliation: Department of Otorhinolaryngology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA.
authors.forename: Vijay K
authors.initials: VK
authors.lastname: Anand
authors.affiliation: Department of Neurosurgery, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Department of Otorhinolaryngology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA; Department of Neurology and Neuroscience, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA. Electronic address: schwarh@med.cornell.edu.
authors.forename: Theodore H
authors.initials: TH
authors.lastname: Schwartz
mesh_terms: D065634:Cerebrospinal Fluid Leak / Q000453:epidemiology* / Q000209:etiology*; D003287:Contrast Media; D004724:Endoscopy / Q000009:adverse effects*; D005260:Female; D019793:Fluorescein; D006801:Humans; D015994:Incidence; D008297:Male; D009296:Nasal Cavity / Q000601:surgery; D018365:Neoplasm, Residual / Q000453:epidemiology; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D010902:Pituitary Gland / Q000601:surgery*; D010911:Pituitary Neoplasms / Q000473:pathology / Q000601:surgery; D012189:Retrospective Studies
chemical_list: D003287:Contrast Media; D019793:Fluorescein
keywords: CSF leak; Endonasal; Endoscopic; Fluorescein; Pituitary